Failure to Honor DNR Order and Verify Code Status Prior to Initiating CPR
Penalty
Summary
The facility failed to ensure that nursing staff followed a resident's do not resuscitate (DNR) order, resulting in the initiation of chest compressions on a resident who had a valid DNR order in place. The resident, who had a diagnosis of pulmonary fibrosis, was found unresponsive in her room by a CNA, who alerted a nurse. The nurse observed the resident to be cyanotic and unresponsive, and called for assistance and a crash cart. Without verifying the resident's code status, another nurse began chest compressions. It was only after another nurse checked and reported the resident's DNR status that chest compressions were stopped. Interviews with staff revealed inconsistent understanding and practices regarding the verification of code status in emergency situations. Some nurses stated they would begin CPR and then verify code status, while others indicated they would check code status first. Additionally, several staff members were unaware of how to access residents' code status during a power outage, as the electronic medical record (EMR) would be inaccessible. This lack of awareness and protocol led to the failure to honor the resident's advance directive. The facility's policy required that code status be checked before initiating CPR, and that residents' advance directives be honored. However, in this incident, the policy was not followed, resulting in the administration of CPR to a resident with a DNR order. The deficiency was identified as Immediate Jeopardy due to the failure to honor the resident's wishes and the lack of staff knowledge regarding code status access during emergencies.
Removal Plan
- Initiate a thorough investigation into the event
- Verify the accuracy for all residents' code status to ensure they align with their wishes
- Provide re-education to all licensed nurses regarding advanced directives and the importance of following physician's orders
- Provide re-education to all licensed nurses on the proper response to an unresponsive resident, as well as code blue and CPR procedures, emphasizing the importance of reviewing advanced directives
- Implement mandatory code blue drills with all licensed nurses and CNAs to reinforce proper response and awareness of advanced directives
- Re-educate all staff members on the definition of neglect, specifically addressing the failure to provide services and care in accordance with a resident's advanced directive wishes